1. The future of biomedical publishing with a few extra thoughts Richard Smith Editor, BMJ www.bmj.com/misc/talks/

2. What I’m going to talk about What’s wrong now with our attempts to provide doctors with the information they need? Why might journals die? Drivers of change for the future of biomedical publishing What might the future look like? For research studies For journals For peer review For meeting the information needs of doctors For pharmaceutical advertising For research misconduct HINARI

3. Current problems A picture that captures in one image how doctors feel about information

5. Current problems One man’s view

7. Current problems Our current information policy resembles the worst aspects of our old agricultural policy, which left grain rotting in thousands of storage files while people were starving. We have warehouses of unused information rotting while critical questions are left unanswered and critical problems are left unresolved. Al Gore

8. Current problems On my desk I have accumulated journals and books as information sources, and I assume that I use them. But in some respects they are not as useful as they might be. Many of my textbooks are out of date; I would like to purchase new ones, but they are expensive. My journals are not organised so that I can quickly find answers to questions that arise, and so I don’t have print sources that will answer some questions. On the other hand, there is likely to be a human source who can answer nearly all of the questions that arise, albeit with another set of barriers. An ordinary doctor

9. Current problems Think of all the information that you might read to help you do your job better. How much of it do you read?

10. 0 0.1 0.2 0.3 0.4 0.5 Less than 1% 1%- 10% 11%- 50% 51%- 90% More than 90% Amount read Percentag e Series2 Series1

11. Current problems Do you feel guilty about how much or how little you read?

13. Words used by 41 doctors to describe their information supply Impossible Impossible Impossible Overwhelming Overwhelming Overwhelming Difficult Difficult Daunting Daunting Daunting Pissed off Choked Depressed Despairing Worrisome Saturation Vast Help Exhausted Frustrated Time consuming Dreadful Awesome Struggle Mindboggling Unrealistic Stress Challenging Challenging Challenging Excited Vital importance

14. Conclusions of studies of doctors’ information needs during consultations Information needs do arise regularly when doctors see patients (about two questions per consultation) Questions are most likely to be about treatment, particularly drugs Questions are often complex and multidimensional The need for information is often much more than a question about medical knowledge. Doctors are looking for guidance, psychological support, affirmation, commiseration, sympathy, judgement, and feedback.

15. Conclusions of studies of doctors’ information needs during consultations Most of the questions generated in consultations go unanswered Doctors are most likely to seek answers to their questions from other doctors Most of the questions can be answered - but it is time consuming and expensive to do so Doctors seem to be overwhelmed by the information provided for them

16. The information paradox: Muir Gray Doctors are overwhelmed with information yet cannot find the information they need

17. Information paradox “Water, water, everywhere Nor any drop to drink” The Rime of the Ancient Mariner

18. What’s wrong with medical journals Don’t meet information needs Too many of them Too much rubbish Too hard work Not relevant Too boring Too expensive

19. What’s wrong with medical journals Don’t add value Slow every thing down Too biased Anti-innovatory Too awful to look at Too pompous Too establishment

20. What’s wrong with medical journals Don’t reach the developing world Can’t cope with fraud Nobody reads them Too much duplication Too concerned with authors rather than readers

21. The future

23. Predictions of Lord Kelvin, president of the Royal Society, 1890-95 Radio has no future X rays will prove to be a hoax Heavier than air flying machines are impossible

24. What are the drivers of a new form of publishing? Failures of the present system A vision of something better Money Balkanisation of the literature Slowness

26. A vision of something better "It's easy to say what would be the ideal online resource for scholars and scientists: all papers in all fields, systematically interconnected, effortlessly accessible and rationally navigable, from any researcher's desk, worldwide for free.” Stevan Harnad

28. A vision of something better If you have an apple and I have an apple and if we exchange these apple then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas. George Bernard Shaw

29. Money What does the research community do? Do the research, often funded by public money, often costing millions Hand over the copyright to the journals Do the editing, often unpaid Do the peer review, almost always unpaid Often do the technical editing, often unpaid Buy the journals, often at inflated prices, some cost $10 000 Read the journals Store the journals

30. Money What do the publishers do? May own the journals, although often they don’t Manage the process Lend the money to keep the process going Design - usually minimal Typeset, print, and distribute the journal Market the journal - but often to libraries that have to have them Sell reprints - sometimes for $250 000 a time (nothing to authors or funders of the research); can almost sell themselves Sell advertising - often none

31. Money Money paid by all academic libraries per article for access to only those libraries that have paid $5000 Money paid by authors per article for whole world to have access $1500